Healthcare Provider Details

I. General information

NPI: 1194611152
Provider Name (Legal Business Name): AVERI TIDWELL
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 WAR EAGLE DR
LEWISBURG TN
37091-9800
US

IV. Provider business mailing address

1031 WAR EAGLE DR
LEWISBURG TN
37091-9800
US

V. Phone/Fax

Practice location:
  • Phone: 931-359-1551
  • Fax:
Mailing address:
  • Phone: 931-359-1551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number279086
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: